NIOSH Publishes Study of Cancer Among Firefighters Claire Reiss National League of Cities Risk Information Sharing Consortium.

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1 NIOSH Publishes Study of Cancer Among Firefighters Claire Reiss National League of Cities Risk Information Sharing Consortium The National Institute for Occupational Safety and Health has released the attached new study 1, Mortality and Cancer Incidence in a Pooled Cohort of US Firefighters from San Francisco, Chicago and Philadelphia ( ). The research has been underway for several years, and we have previously brought it to your attention. This paper summarizes and identifies questions about the study s important conclusions, and discusses how it relates to the 2009 study published by the National League of Cities, Assessing State Firefighter Cancer Presumption Laws and Current Firefighter Cancer Research. 2 The NIOSH study may not be representative of the typical exposures faced in the fire departments insured by NLC-RISC member pools. The NIOSH report focuses on 59 years of data about 30,000 career firefighters at three big-city fire departments: Philadelphia, Chicago and San Francisco. These are all old-line cities where the firefighters would be expected to fight more fires and encounter asbestos and chemicals more often and in greater concentrations than in the smaller cities and towns typical of our membership. The career service is important, certainly, as it protects 66% of the U.S. population, but almost 70% of 1,129,250 firefighters in the U.S. are volunteers, and 85% of U.S. fire departments are all or mostly volunteer. 3 A large part of the U.S. is protected by those volunteers in low population or rural settings. The type and extent of their exposure may well differ, and they are not part of the NIOSH study cohort. NIOSH says that this study strengthens the evidence of a relationship between firefighting and certain cancers. The report and commentary suggest that firefighters have a slightly elevated risk compared to the general population, but when you look at the body of the report the significance of the excess experience for some cancers is less certain. Discerning the real significance requires careful reading of the discussion section, not just review of the statistical results. There are important issues NLC-RISC member pools may want to consider for use in their advocacy efforts on presumption legislation. First, the NIOSH study does not identify the strength of association criteria it uses to evaluate the causal relationship between an activity and an illness. However, a presentation about the NIOSH study by one of its primary researchers at the Redmond Symposium on the Occupational Health and Hazards of the Fire Service does identify 1 Mortality and Cancer Incidence in a Pooled Cohort of US Firefighters from San Francisco, Chicago and Philadelphia ( ), National Institute of Occupational Safety and Health, Assessing State Firefighter Cancer Presumption Laws and Current Firefighter Cancer Research, National League of Cities, April NFPA Fire Department Profile for 2012, 1

2 strength of association criteria. 4 According to that presentation, ratios equal to 1 indicate cancer mortality or incidence similar to the overall population. Any ratio in excess of 1, however small, indicates an excess experience. Neither the study nor the presentation indicate when an excess experience becomes sufficiently strong to show an association. The 2009 National League of Cities research adopted specific strength of association criteria that were identified during the literature review. Those criteria require a range of 1.2 to 1.5 excess experience to show even a weak strength of association. 1.5 to 3 was considered to be a moderate strength of association. Association was not considered to be strong until the ratio reached 3 and above. 5 The NIOSH strength of association criteria thus appear to be significantly more liberal than those used in the NLC study, because they do not establish even a minimal buffer for sampling variability. Second, despite its use of weaker standards for determining strength of association, the NIOSH study still finds only small to moderate increases in risk for several cancer sites and for all cancers combined, stemming mostly from excess malignancies of the respiratory, digestive, and urinary systems. 6 The ratios for the list of cancers NIOSH finds to show small to moderate increase in mortality and/or incidence are: Cancer SMR (Mortality ratio) SIR (Incidence ratio) All cancer Bladder Buccal and pharynx Esophagus Intestine Kidney Laryngeal N/A 1.50 Liver, gall bladder, biliary Lung Malignant mesothelioma Rectum When these ratios are evaluated using the strength of association criteria from the NLC study, malignant mesothelioma is the lone cancer to reflect both a moderate level of excess mortality/incidence (2.0/2.29 in a range of ) and an association with a risk 4 NIOSH Firefighter Cancer Study Workshop, August 24, 2013, Robert D. Daniels, PhD and Thomas Hales, MD, MPH, IAFF John P. Redmond Symposium on the Occupational Health and Hazards of the Fire Service, Slide 7. Available online (cut and paste link into a browser to access) 5 Supra, p Mortality and Cancer Incidence in a Pooled Cohort of US Firefighters, supra, p. 9 2

3 factor, asbestos exposure, which is recognized to occur in firefighting. The mortality and incidence for all cancers and for lung cancer are so low as to be in the no association category (less than 1.2). Of the remaining cancers NIOSH identifies as excess, all show only a weak association under the NLC study strength of association criteria except esophageal cancer, laryngeal cancer and malignant mesothelioma. Those cancers show a moderate association. However, as the NIOSH authors acknowledge, the primary known risk factors for esophageal and laryngeal cancer are not related to firefighting, so the elevation may be due to some other characteristic that firefighters have in common. Third, the NIOSH study shows that numerous cancers already targeted by state presumption statutes do not have a significant excess incidence or mortality in firefighters as compared to the rest of the population. Even where there is an apparent excess of cases, the authors sometimes conclude that other risk factors were more likely causes. The discussion section of the NIOSH report made the following important observations: There is little evidence of excess cancers of the testes, brain and lymphohematopoietic systems. 7 In women, there is statistical evidence of excess female bladder and breast cancers, but only bladder cancer mortality and incidence reach significance. The report notes: There is little evidence linking female breast cancer to workplace exposures, however prolonged shift work may be a risk factor. The report urges cautious interpretation of the findings on female firefighters due to the small sample size and lack of confirmatory results. 8 There are excess digestive cancers, primarily of esophageal and colorectal sites, but the report notes that information on occupational causes is sparse, with only limited evidence suggesting asbestos and diesel exhaust exposure may be weakly associated with gastrointestinal cancers. The report observes the relation between these hazardous exposures and digestive cancers appears small compared to the effects of other factors such as diet, obesity, physical activity, tobacco use and alcohol consumption. 9 The important risk factors for the increased oral, pharyngeal and laryngeal cancers are tobacco and alcohol consumption, with lesser evidence that exposures to wood dusts, smoke, asbestos, PAHs and acid mists may also increase risk. 10 The excess bladder and prostate cancer incidence (there is no excess mortality) is limited to firefighters between 45 and 59 year old. The report notes that differences in medical screening (e.g., prostate-specific antigen tests) among 7 Supra, p Supra, p Supra, p Supra, p. 8. 3

4 firefighters compared to the general population, as well as firefighting itself, could have contributed to the observed excess. 11 Malignant mesothelioma is an exception. The study finds a previously unreported twofold excess of malignant mesothelioma among firefighters. It notes that asbestos is the only known causal agent for this cancer and that firefighter exposures to asbestos are probable, so it is likely that this excess represents a true causal connection. 12 This result should not be entirely unexpected, given the age and construction of the old-line cities studied, which would be expected to pose a greater risk of exposure to asbestos. Fourth, much work remains to be done. The study describes itself as the first phase of examining health effects in career firefighters, and as the foundation for subsequent analysis, not as the last word. The presentation by the NIOSH study authors at the Redmond Symposium acknowledges several limitations: Low statistical power it is difficult to observe the effect due to the long latency of the disease and the small effect size 13. Few women and minority firefighters are included. Estimates could be influenced by other factors, including other risk factors, such as tobacco use, alcohol consumption, diet and obesity, information on which was noted to be lacking. The need to further evaluate other risk factors is particularly important, and the Redmond Symposium presentation notes that they will be the subject of follow up research to evaluate exposure and response. That research will estimate exposure for each firefighter by looking at all jobs held and their duration, defining the exposure potentials for those jobs, and modifying the exposure potentials during fire service based on information about fire runs, diesel exhaust controls in the station, PPE use and other factors that may affect exposure. 14 Finally, compared to the incidence in the population as a whole, the excess cancers identified by NIOSH are relatively few. For example, the mortality of 1.10 for lung cancer is based on 1,046 observations : firefighters in the cohort identified as dying from lung cancer. With a ratio of 1.10, only 10% of those deaths are actually in excess of what would be expected in the population as a whole. Thus, the actual number of excess lung cancer deaths identified over the entire 59-year period studied is 95, as compared to 951 firefighters whose disease is consistent with the incidence in the population as a 11 Supra, p. 8. Also note that recently a number of organizations are cautioning against the routine use of this screening for several reasons, including the incidence of false positives Supra, p A measure describing the magnitude of the difference between two groups. Texas Education Agency, 14 NIOSH Firefighter Cancer Study Workshop, Supra, Slide 18. 4

5 whole, and the 160,340 Americans that were expected to die from lung cancer in 2012 alone. 15 The same analysis can be applied to any of the other cancers studied, and it illustrates how small an excess experience has been identified thus far, and the need for additional research to determine whether there is a true causal relation with firefighting. Conclusion The relationship between firefighting and cancer is an issue that is likely to remain on the front burner. More study is needed, especially about the effect of non-employment related risk factors, before any conclusions can be drawn that are sufficiently robust to support a change in public policy. Nor is the issue exclusive to firefighters, as many people in other lines of work are exposed to carcinogenic substances without any worker s compensation presumption to benefit them. The ongoing nature of this issue and the difficulty of establishing any strong relationship in many cases raises the question of whether our efforts should be directed to reducing the risk to firefighters rather than to establishing programs that will provide compensation on a presumptive basis to a large group of people who statistically would have developed the illness whatever their occupation. We are available for questions and further exploration of this issue. 15 Lung Cancer Fact Sheet, American Lung Association, 5

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